The reality of trans pathologization in Russia
By Yana Kirey-Sitnikova
Note: The article contains descriptions of violence and involuntary medical treatment.
Psychiatric treatment of transgender people has recently received attention in media and medical literature in response to strong international campaigns for depathologization, organized by transgender activists. The debates grew even stronger surrounding the drafting of the 5th version of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which resulted in the replacement of “Gender Identity Disorder” with arguably less stigmatizing “Gender Dysphoria”, as well as current drafting of the 11th version of International Classification of Diseases (ICD-11). Psychiatrization of gender variability has been criticized as nothing more than social control, on the basis of the poor validity of diagnostic criteria, cross-cultural evidence, etc. Focusing on global theoretical issues, the analysis of many authors uncritically examines the impact of the diagnosis on the lives of transgender people; in particular, the legal and political contexts, especially in countries outside the USA and Europe. While social stigmatization associated with the pathologization of trans expression is central in these debates, the experience of transgender people in psychiatric institutions is less often discussed.
In this article, I will discuss the way the existence of the diagnosis “Transsexualism” in any form, both current and suggested for the next revision of ICD, leads to psychiatric abuse and negatively impacts the lives of transgender people in Russia. I will first discuss the historical background and legal framework in which transgender people seek a diagnosis. Secondly, I will describe the experiences of transgender people in psychiatric institutions, obtained from online accounts. Finally, I will discuss the ways in which different models of depathologization and may possibly impact transgender people in Russia.
A brief historical background will help readers understand the context in which psychiatric oppression of transgender people operates in Russia. Psychiatry was used systematically as a weapon against political dissidents in the Soviet Union in the 1960s. The infamous diagnosis “sluggish schizophrenia” was used to detain opponents of the government and other people in mental hospitals for behavior that was considered as going against social norms, where their compulsory treatment was performed.
There’s no evidence that transgender people in USSR were intentionally subject to political abuse of psychiatry for the simple reason they were invisible. However, when they appeared in front of the psychiatrist, either by their own will or by the will of those who considered trans expression to be deviant, they were faced with the same cruel system, which goal was not the person’s welfare but reproduction of social norms and official ideology. According to an interview with a trans* woman which appeared in the press, in 1961 when she first tried to get help from the doctors, she was “beaten and pricked to dullness” and received the diagnosis “Paranoid schizophrenia”. Due to the preoccupation of Soviet psychiatry with “schizophrenia”, it seems that this diagnosis was often given to transgender people (however, direct evidence for that period is difficult to find).
This historical context would not appear in this article if it was not to some degree similar to the situation in post-Soviet Russia. Although on a smaller scale, punitive psychiatry is reviving in present-day Russia, the latest case is that of Mikhail Kosenko, a protester at the Bolotnaya Square in 2012, who was diagnosed with “paranoid schizophrenia” and forced to receive psychiatric treatment. As the reader will see, the attitude towards transgender people in Russian psychiatry continues to follow the Soviet model in some forms.
Many transgender people need to change their names and legal gender in order not to be discriminated against. This procedure known as legal gender recognition (LGR) is not clearly defined in Russian law. The federal law N143 “On the acts of civil status” briefly mentions the possibility of LGR in article 70: “Conclusion on making amendments or changes to the statement of the act of civil status is made by the civil registry in case if <…> a document of the established form about the change of sex issued by a medical organization is submitted”. However, no exact “document of the established form” exists that gives the legal registries and the courts room to judge which medical interventions a person must accomplish in order to be eligible for LGR. The two requirements (usually both of them) must be present in most of the cases: psychiatric diagnosis F64.0 “Transsexualism” (according to ICD-10, which is currently used in Russia) and/or sex reassignment surgery. Even if the diagnosis is not explicitly required, doctors will not perform trans surgery care without it, with few exceptions. That makes psychiatric assessment a de facto requirement for transgender individuals who wish to change their legal status.
Procedure Within Russia, there exists no centralized body for issuing the diagnosis “Transsexualism” (F64.0) (unlike, for example, in Ukraine). What’s more, there are a low number of non-transphobic doctors who have a deep understanding of trans* issues. Until recently, there was only one such psychiatrist in the whole country — Dmitry Isaev, who works in St. Petersburg. Another clinic which positions itself as trans* friendly — Department of Reconstructive Surgery, Andrology and Sexopathology (RSAS) — opened in Moscow in 2013. Given the long distances, not many trans* people from Siberia and the Far East can afford to travel to St. Petersburg or Moscow. Moreover, they may be required to visit a psychiatrist several times before they receive their diagnosis. These circumstances limit their choice to local facilities where doctors tend to be ignorant of trans* issues, extremely transphobic and/or rude.
The treatment of transgender patients was previously described in the Decree of the Ministry of Health N311 “Models of diagnostics and treatment of mental and behavioral illnesses”, enacted in 1999. The negative impacts of this Decree on the psychiatric practice will be discussed later in this article. In 2012 the Decree was repealed, and in 2013 the “Standard of primary medical care in the case of sexual identity disorders” was introduced in its place (the exact reason for this change is not known to me, but it definitely is not connected to pressure from human rights activists). The new document requires examinations by a psychotherapist, psychiatrist, sexologist, endocrinologist and medical psychologist for individuals who wish to obtain the diagnosis “Transsexualism”. It’s too early to judge whether these amendments will result in any change in psychiatric practice. The new Standard is very short and mentions only the specialists which a trans* person must visit an average number of appointments with each of them. It also mentions the drugs that can be used for hormone-replacement therapy (only four drugs are on the list, that may hinder future access to other drugs) and their average doses. Unlike the Decree N311, it doesn’t explain the criteria and recommended treatment; therefore, the old Decree may be retained as an unofficial guide for psychiatrists.
Psychiatrist interview Obtaining the diagnosis “Transsexualism” usually requires several appointments with a psychiatrist. Additional inspections by a sexologist, psychologist, gynecologist, as well as hormones and karyotype tests are usually required. If the psychiatrist considers the applicant appropriate, a commission of several medical practitioners is appointed.
Experience of trans* people during the interviews with psychiatrists and the commission varies significantly, from quite positive or neutral reviews, as far as St.-Petersburg and Moscow are concerned, to horrific in many other places. No matter which place, trans* people are almost always misgendered and are referred to by their legal names. Asking about the applicant’s personal and sexual life is another widespread practice. Here’s a fragment of conversation between Alexandr Bukhanovsky, a psychiatrist in “Phoenix” psychiatric clinic, Rostov-on-Don, and a trans* man:
Bukhanovsky: Do you have natural sexual intercourse?
Trans man: What do you mean by natural?
Bukhanovsky: As a woman or anally?
Trans man: Anally.
Bukhanovsky: Do you take off clothes when in an intimate relationship?
One trans* woman who was assessed for “transsexualism” at the Moscow Research Institute of Psychiatry reported that 90% of questions were about “sex, masturbation, anal stimulation, nocturnal emission [and] fantasies”. After her assessment, she was told that she’s not a “typical” transsexual but an obsessive homosexual.
Sex-related questions can be accompanied by general rudeness towards the patient, as follows from the questions a trans* woman was asked by Mikhail Beil’kin, a sexologist from Chelyabinsk:
- So why the fuck do you need a vagina?
- What the hell brought you here?
- When was the last time you fucked with your wife?
- Why the shit do you want a vagina, if you don’t like boys?
This conversation brings us to the intersection of gender identity and sexual orientation. Although a few progressive psychiatrists accept that a trans* person can have any sexual orientation, most still insist that one must be heterosexual in their gender of choice in order to be “trans enough”. The mentioned above Decree N311 listed “homosexual orientation” (according to sex, assigned at birth) as one of the symptoms of “Transsexualism”.
It is common that psychiatrists make offensive comments about the applicant’s appearance, this usually goes together with an attempt to dissuade one from changing gender. This was actually one of the steps of “psychotherapy” aimed at “reconciliation with the innate sex”, according to Decree N311. “You’ll never become a real woman, and no normal man will want to have an affair with you”, “You will never look thoroughly like a woman” — a friend of mine was told during the commission in RSAS, Moscow. Bukhanovsky told a trans man, “Outwardly, I would not say that you are a man”. A trans* person’s ability to present a stereotypical gender appearance plays an important role in receiving the diagnosis in most cases, although this depends on the psychiatrist. For example, a trans* woman in Krasnoyarsk was yelled at for wearing “female” clothes by doctor Andrej Sumarokov. When trying to dissuade trans* people, psychiatrists use not only cissexist and heterosexist commentary, but patriarchal arguments as well: “You are choosing the wrong way for fulfilling your destined function, you have everything physiological and biological… you could become pregnant…” (Bukhanovsky, to a trans* man).
Inspection by a psychiatrist is not enough in many cases and transgender people are required to stay in a psychiatric institution for around 30 days. Feedback on this experience vary from “it was better than expected” to what may be defined as psychiatric torture. In less common cases, transgender people are hospitalized against their will upon the demand of their parent. This may happen to minors under 15 years old, who can be hospitalized with the consent of their parents, according to the Law “On Psychiatric Care”. Due to high levels of corruption in Russian health system, transgender individuals older than 15 can also be hospitalized against their will: “For a bribe, I was locked in psikhushka [Russia word for mental hospital], and fed with Zyprexa [antipsychotic drug] and was told that I had schizophrenic delusions as a result of birth trauma”.
Whether voluntarily hospitalized or not, transgender individuals are placed in the facilities with other patients according to their legal gender, that is different from the one they identify with. This can lead to hostility and violence from other patients. A trans* woman describes having been raped thrice, with no effort of the personnel to stop it: “My parents recommended to put me in hospital and cure my head of folly. Of course, I tried to arrange to receive a permission [diagnosis of “Transsexualism”] with doctors, however, no one listened to me and put me to a “tigers’ cage”, that is a cell for violently mentally ill patients. What’s important, I got there in the female clothes and I was immediately pressed there, even raped three times by some bastards, but the staff didn’t care!” Finally, this woman received the diagnosis “Schizotypal personality disorder” and had to pass psychiatric assessment again in a different city to get the required diagnosis “Transsexualism”.
Psychiatric torture is widespread in mental hospitals. Before hospitalization, transgender individuals are made to agree to the use of drug treatments — even though their goal is to receive a diagnosis, not to be “treated”. The following story, which happened in Krasnoyarsk, describes what this treatment might look like: “I went through 30 days of a madhouse. The most difficult — I was injected with neuroleptics without receiving antidotes for more or less normal feeling. I was subject to the method of pressurizing psychopathy and 24 hours a day they observed — whether I will cope with it or will go mad”. This person reported that no one told her what she was being “treated” for and which drugs were used, however, after a month she received a “Transsexualism” diagnosis. What’s more astonishing is that such mistreatment is not only the result of the incompetence of individual doctors but is officially described in Decree N311 as a method of pharmacotherapy “in cases of psychogenic diseases, with employment of tranquilizers, antidepressants, anxiolytics, nootropics, sedatives”.
When talking about other issues, taking hormones may be prohibited in some hospitals. This measure not only violates the rights of body integrity and gender expression but also is harmful to the health of transgender individuals who had started taking hormones before hospitalization.
The situation described above obviously needs to be changed. Generally speaking, two options are possible. Actions aimed at educating psychiatrists about trans* issues on the national level may be one option. This, however, proves to be hardly possible in the current political situation in Russia and complete unwillingness of most psychiatrists to listen to trans* activists’ arguments (whom they perceive as patients, not equal participants in the dialogue). What’s more, even in the case of success, it will not remove the system of “gatekeeping” (controlling access to gender recognition), but will only make it a little less oppressive. However, I would be wrong if I said that these actions are unnecessary, as the situation of transgender people illustrates only one example of a violation of psychiatric patients’ rights in Russia.
The second, long-term option is to radically change the whole psychiatric approach to gender variance on the international level. Steps in this direction started a few years ago, since the establishment of the International Campaign “Stop Trans Pathologization” and other activist groups. Thanks to the pressure of activists and researchers, the recently released beta draft of the next version of ICD (ICD-11 beta) made a long-awaited shift away from treating transgender expression as a mental disease. In this draft, trans* issues were moved from Section F “Mental and behavioral disorders” (in ICD-10) to a newly created chapter “Gender incongruence” under section 6 “Conditions related to sexual health” (in ICD-11).
Unfortunately, this alteration cannot be regarded as complete depathologization, but rather re-pathologization (that is pathologization under a different category). The existence of the diagnosis in this form does not reduce the vulnerability of transgender individuals towards humiliations they experience from the state and psychiatric institutions, at least in Russia. Nothing will stop the Registry or a judge from demanding a trans* person to be diagnosed with “Gender Incongruence” (instead of “Transsexualism”) to be eligible for legal gender recognition. Nothing will stop a surgeon from demanding the diagnosis from a person wishing to undergo a genital surgery (which itself is required for the amendment of gender marker in many cases). And finally, the fact that “Gender incongruence” will no longer be a psychiatric disorder (but rather a sexual disorder) will not prohibit psychiatrists from participating in the process of assessment — just as the fact that “Transsexualism” is now considered a mental illness is not an obstacle for accounting the opinion of sexologists and endocrinologists. Moreover, in this scenario, psychiatrists will definitely remain involved in the process to make sure that a person doesn’t have schizophrenia. That’s why, in my opinion, the suggested re-pathologization will not reduce psychiatric abuse of transgender individuals described in this article.
My firm conviction is that the solution may be found in moving trans* related issues to the non-pathologist section 24 in ICD-11 (which corresponds to section Z in ICD-10) “Factors influencing health status and contact with health services” and renamed as “Body modifications related to secondary sex characteristics”. The ascent should be made not on gender identity and its relation to morphological sex but only on the needs for body modifications (with hormones and/or operations). This approach will preserve the ability for transgender people to receive medical assistance during their physical transition (in case they wish to undergo such transition) and at the same time reduce the possibilities of abuse from the state and psychiatric institutions.
Unfortunately, many activists from Western countries do not support the suggested model on the basis that it might affect the possibility of insurance coverage for hormones and operations. It is a highly controversial issue (in my opinion, moving the diagnosis to the non-pathologist category will not make coverage impossible), and no ideal model exists. However, when discussing pros and cons of each model, I want activists from other parts of the world to know better local situation in different countries and take into account that in some of them medical systems are much harsher and hostile than in their own.
Kirey-Sitnikova is a transfeminist activist from Moscow and a Ph.D. student in chemoinformatics at the University of Strasbourg.
TERF opinion leader, author, and speaker Sheila Jeffreys asserted that trans surgical care in the west is like “political psychiatry” in Russia. Her hyperbole was published in a peer-reviewed journal:
[Transsexual surgery] could be likened to political psychiatry in the Soviet Union. I suggest that transsexualism should best be seen in this light, as directly political, medical abuse of human rights. The mutilation of healthy bodies and the subjection of such bodies to dangerous and life-threatening continuing treatment violates such people’s rights to live with dignity in the body into which they were born, what Janice Raymond refers to as their “native” bodies. It represents an attack on the body to rectify a political condition, “gender” dissatisfaction in a male supremacist society based upon a false and politically constructed notion of gender difference. Recent literature on transsexualism in the lesbian community draws connections with the practices of sadomasochism. – Sheila Jeffreys
American TERFs are trying to flood WHO with comments encouraging WHO to not reform their ICD classifications for trans people. For example, one TERF commenter asserted:
[A]ny correct terminology for the transsexual lobby (in both its commercial and non-profit guises) must address the mental disorder of dysmorphia and the dissociation that drives hormonal manipulation & surgical altering to create a costume out of the physical body – rather than to address the psychological disorder at the root of rejection of the physical body and reliance on lifelong artificial means of sustaining it.